Longitudinal Monitoring of Clinician-Patient Video Visits During the Peak of the COVID-19 Pandemic: Adoption and Sustained Challenges in an Integrated Health Care Delivery System.

BACKGROUND: Numerous prior opinion papers, administrative electronic health record data studies, and cross-sectional surveys of telehealth during the pandemic have been published, but none have combined assessments of video visit success monitoring with longitudinal assessments of perceived challenges to the rapid adoption of video visits during the pandemic. OBJECTIVE: This study aims to quantify (1) the use of video visits (compared with in-person and telephone visits) over time during the pandemic, (2) video visit successful connection rates, and (3) changes in perceived video visit challenges. METHODS: A web-based survey was developed for the dual purpose of monitoring and improving video visit implementation in our health care system during the COVID-19 pandemic. The survey included questions regarding rates of in-person, telephone, and video visits for clinician-patient encounters; the rate of successful connection for video visits; and perceived challenges to video visits (eg, software, hardware, bandwidth, and technology literacy). The survey was distributed via email to physicians, advanced practice professionals, and clinicians in May 2020. The survey was repeated in March 2021. Differences between the 2020 and 2021 responses were adjusted for within-respondent correlation across surveys and tested using generalized estimating equations. RESULTS: A total of 1126 surveys were completed (511 surveys in 2020 and 615 surveys in 2021). In 2020, only 21.7% (73/336) of clinicians reported no difficulty connecting with patients during video visits and 28.6% (93/325) of clinicians reported no difficulty in 2021. The distribution of the percentage of successfully connected video visits ("Over the past two weeks of scheduled visits, what percentage did you successfully connect with patients by video?") was not significantly different between 2020 and 2021 (P=.74). Challenges in conducting video visits persisted over time. Poor connectivity was the most common challenge reported by clinicians. This response increased over time, with 30.5% (156/511) selecting it as a challenge in 2020 and 37.1% (228/615) in 2021 (P=.01). Patients not having access to their electronic health record portals was also a commonly reported challenge (109/511, 21.3% in 2020 and 137/615, 22.3% in 2021, P=.73). CONCLUSIONS: During the pandemic, our health care delivery system rapidly adopted synchronous patient-clinician communication using video visits. As experience with video visits increased, the reported failure rate did not significantly decline, and clinicians continued to report challenges related to general network connectivity and patient access to technology.

Implementing a Second-Level Observation Unit at a Large Academic Medical Center.

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Food Insecurity Is Associated with an Increased Prevalence of Comorbid Medical Conditions in Obese Adults: NHANES 2007-2014.

BACKGROUND: Numerous studies have examined if food insecurity (FI) leads to increased weight gain, but little is known about how FI affects obese participants. OBJECTIVE: Our objective was to determine if obese, food-insecure adults are more likely to have medical comorbidities than obese, food-secure adults. DESIGN: We conducted a cross-sectional study using the 2007-2014 National Health and Nutrition Examination Survey (NHANES). PARTICIPANTS: All obese participants (≥ 20 years) in NHANES were eligible. Participants who were pregnant or missing FI data were excluded. MAIN MEASURES: The primary exposure was household FI, and the primary outcome was the total number of obesity-related comorbidities. Secondary outcomes evaluated the association between FI and individual comorbidities. Propensity score weighting was used to improve covariate balance. We used negative binomial regression to test the association between FI and the total number of comorbidities. We used logistic regression to test the association between FI and individual comorbidities. KEY RESULTS: Of the 9203 obese participants, 15.6% were food insecure. FI (ß = 0.09, 95% CI: 0.02, 0.15; p = 0.01) and very low food security (ß = 0.17, 95% CI: 0.07, 0.28; p = 0.003) were associated with an increased number of comorbidities. In secondary analyses, FI was associated with increased odds of coronary artery disease (OR: 1.5, 95% CI: 1.1, 2.0) and asthma (OR: 1.3, 95% CI: 1.1, 1.6). Very low food security was associated with increased odds of coronary artery disease, diabetes, and asthma. CONCLUSION: Obese adults living in food-insecure households were more likely to have an increased number of comorbid conditions than obese adults living in food-secure households. Clinicians should be aware of the association between FI and comorbid medical conditions when treating patients with obesity.

Pragmatic clinical trials embedded in healthcare systems: generalizable lessons from the NIH Collaboratory.

BACKGROUND: The clinical research enterprise is not producing the evidence decision makers arguably need in a timely and cost effective manner; research currently involves the use of labor-intensive parallel systems that are separate from clinical care. The emergence of pragmatic clinical trials (PCTs) poses a possible solution: these large-scale trials are embedded within routine clinical care and often involve cluster randomization of hospitals, clinics, primary care providers, etc. Interventions can be implemented by health system personnel through usual communication channels and quality improvement infrastructure, and data collected as part of routine clinical care. However, experience with these trials is nascent and best practices regarding design operational, analytic, and reporting methodologies are undeveloped. METHODS: To strengthen the national capacity to implement cost-effective, large-scale PCTs, the Common Fund of the National Institutes of Health created the Health Care Systems Research Collaboratory (Collaboratory) to support the design, execution, and dissemination of a series of demonstration projects using a pragmatic research design. RESULTS: In this article, we will describe the Collaboratory, highlight some of the challenges encountered and solutions developed thus far, and discuss remaining barriers and opportunities for large-scale evidence generation using PCTs. CONCLUSION: A planning phase is critical, and even with careful planning, new challenges arise during execution; comparisons between arms can be complicated by unanticipated changes. Early and ongoing engagement with both health care system leaders and front-line clinicians is critical for success. There is also marked uncertainty when applying existing ethical and regulatory frameworks to PCTS, and using existing electronic health records for data capture adds complexity.

Gatekeepers as Care Providers: The Care Work of Patient-centered Medical Home Clerical Staff.

International implementation of the patient-centered medical home (PCMH) model for delivering primary care has dramatically increased in the last decade. A majority of research on PCMH's impact has emphasized the care provided by clinically trained staff. In this article, we report our ethnographic analysis of data collected from Department of Veterans Affairs staff implementing PACT, the VA version of PCMH. Teams were trained to use within-team delegation, largely accomplished through attention to clinical licensure, to differentiate staff in providing efficient, patient-centered care. In doing so, PACT may reinforce a clinically defined culture of care that countermands PCMH ideals. Such competing rubrics for care are brought into relief through a focus on the care work performed by clerks. Ethnographic analysis identifies clerks' care as a kind of emotional dirty work, signaling important areas for future anthropological study of the relationships among patient-centered care, stigma, and clinical authority.

The Critical Role of Clerks in the Patient-Centered Medical Home.

Research evaluating the effectiveness, function, and implementation of patient-centered medical homes (PCMHs) has found major socioprofessional transformations and contributions of primary care physicians and, to a lesser degree, nurses. Our longitudinal ethnographic research with teams implementing PCMH in Veterans Health Administration (VHA) primary care identifies the important but largely underutilized contributions of clerks to PCMH outcomes. Although the relationship of high-performing clerical staff to patient satisfaction is widely acknowledged, PCMH can be further enhanced by enabling clerks to use administrative tasks as conduits for investing in long-term personalized relationships with patients that foster trust in the PCMH and the broader health care organization. Such relationships are engendered through the care-coordination activities clerks perform, which may be bolstered by organizational investment in clerks as skilled health care team members.

Insurance status and the transfer of hospitalized patients: an observational study.

BACKGROUND: There is little objective evidence to support concerns that patients are transferred between hospitals based on insurance status. OBJECTIVE: To examine the relationship between patients' insurance coverage and interhospital transfer. DESIGN: Data analyzed from the 2010 Nationwide Inpatient Sample. PATIENTS: All patients aged 18 to 64 years discharged alive from U.S. acute care hospitals with 1 of 5 common diagnoses (biliary tract disease, chest pain, pneumonia, septicemia, and skin or subcutaneous infection). MEASUREMENTS: For each diagnosis, the proportion of hospitalized patients who were transferred to another acute care hospital based on insurance coverage (private, Medicare, Medicaid, or uninsured) was compared. Logistic regression was used to estimate the odds of transfer for uninsured patients (reference category, privately insured) while patient- and hospital-level factors were adjusted for. All analyses incorporated sampling and poststratification weights. RESULTS: Among 315 748 patients discharged from 1051 hospitals with any of the 5 diagnoses, the percentage of patients transferred to another acute care hospital varied from 1.3% (skin infection) to 5.1% (septicemia). In unadjusted analyses, uninsured patients were significantly less likely to be transferred for 3 diagnoses (P 0.05). In adjusted analyses, uninsured patients were significantly less likely to be transferred than privately insured patients for 4 diagnoses: biliary tract disease (odds ratio, 0.73 [95% CI, 0.55 to 0.96]), chest pain (odds ratio, 0.63 [CI, 0.44 to 0.89]), septicemia (odds ratio, 0.76 [CI, 0.64 to 0.91]), and skin infections (odds ratio, 0.64 [CI, 0.46 to 0.89]). Women were significantly less likely to be transferred than men for all diagnoses. LIMITATION: This analysis relied on administrative data and lacked clinical detail. CONCLUSION: Uninsured patients (and women) were significantly less likely to undergo interhospital transfer. Differences in transfer rates may contribute to health care disparities. PRIMARY FUNDING SOURCE: National Institutes of Health.

Racial disparities in outcomes after cardiac surgery: the role of hospital quality.

Patients from racial and ethnic minorities experience higher mortality after cardiac surgery compared to white patients, both during the early postoperative phase as well as long term. A number of factors likely explain poor outcomes in black and minority patients, which include differences in biology, comorbid health conditions, socioeconomic background, and quality of hospital care. Recent evidence suggests that a major factor underlying excess mortality in these groups is due to their over-representation in low-quality hospitals, where all patients regardless of race have worse outcomes. In this review, we examine the factors underlying racial disparities in outcomes after cardiac surgery, with a primary focus on the role of hospital quality.

Racial disparities in knee and hip total joint arthroplasty: an 18-year analysis of national Medicare data.

OBJECTIVE: To examine whether racial disparities in usage and outcomes of total knee and total hip arthroplasty (TKA and THA) have declined over time. METHODS: We used data from the US Medicare Program (MedPAR data) for years 1991-2008 to identify four separate cohorts of patients (primary TKA, revision TKA, primary THA, revision THA). For each cohort, we calculated standardised arthroplasty usage rates for Caucasian and African-American Medicare beneficiaries for each calendar year, and examined changes in disparities over time. We examined unadjusted and adjusted outcomes (30-day readmission rate, discharge disposition etc.) for Caucasians and African-Americans, and whether disparities decreased over time. RESULTS: In 1991, the use of primary TKA was 36% lower for African-Americans compared with Caucasians (20.6 per 10,000 for African-Americans; 32.1 per 10,000 for Caucasians; p<0.0001); in 2008, usage of primary TKA was 40% lower for African-Americans (41.5 per 10,000 for African-Americans; 68.8 per 10,000 for Caucasians; p<0.0001) with similar findings for the other cohorts. Black-White disparities in 30-day hospital readmission increased significantly from 1991-2008 among three patient cohorts. For example in 1991 30-day readmission rates for African-Americans receiving primary TKA were 6% higher than for Caucasians; by 2008 readmission rates for African-Americans were 24% higher (p<0.05 for change in disparity). Similarly, black-white disparities in the proportion of patients discharged to home after surgery increased across the study period for all cohorts (p<0.05). CONCLUSIONS: In an 18-year analysis of US Medicare data, we found little evidence of declines in racial disparities for joint arthroplasty usage or outcomes.

Structuring payment to medical homes after the affordable care act.

The Patient-Centered Medical Home (PCMH) is a leading model of primary care reform, a critical element of which is payment reform for primary care services. With the passage of the Affordable Care Act, the Accountable Care Organization (ACO) has emerged as a model of delivery system reform, and while there is theoretical alignment between the PCMH and ACOs, the discussion of physician payment within each model has remained distinct. Here we compare payment for medical homes with that for accountable care organizations, consider opportunities for integration, and discuss implications for policy makers and payers considering ACO models. The PCMH and ACO are complementary approaches to reformed care delivery: the PCMH ultimately requires strong integration with specialists and hospitals as seen under ACOs, and ACOs likely will require a high functioning primary care system as embodied by the PCMH. Aligning payment incentives within the ACO will be critical to achieving this integration and enhancing the care coordination role of primary care in these settings.

The role of pragmatic clinical trials in the evolution of learning health systems.

Pragmatic clinical trials (PCTs) test clinical interventions (eg, treatments, diagnostic tests, delivery strategies) that are widely used in practice and for which there is often clinical equipoise. Similar to traditional explanatory trials of novel therapeutics, PCTs use randomization to decrease selection bias. In contrast, PCTs rely on extant data sources (eg, electronic medical records [EMRs]) and test interventions that can be implemented with minimal research infrastructures. Thus, PCTs have drawn interest as vehicles for decreasing the cost of clinical research and for creating learning health systems, which, as articulated by the Institute of Medicine, seek to generate new knowledge as an integral by-product of the delivery experience. However, realizing this vision for PCTs will require innovative approaches for engaging clinicians, improving the efficiency of subject recruitment, improving the reliability of EMR data, and new paradigms for the regulatory review of low-risk trials to decrease unncessary hurdles to practice-based knowledge generation.

Patterns of illness explaining the associations between posttraumatic stress disorder and the use of CT.

PURPOSE: To examine the relationship between posttraumatic stress disorder (PTSD) and computed tomography (CT) utilization and to determine whether there were patterns of comorbid illness that could explain the relationship. MATERIALS AND METHODS: The study was approved by the University of Iowa Institutional Review Board and the Iowa City Veterans Affairs Medical Center Research and Development Committee. By using a retrospective cohort design, a national sample of new veteran enrollees aged 18-35 years was studied. Associations were examined between the presence of PTSD, receipt of at least one and multiple CT scans, comorbid medical conditions (eg, abdominal pain, headaches), and measures of health care utilization (eg, primary care, emergency room, and mental health visits) and the daily probability of the receipt of at least one CT scan before and after a diagnosis of PTSD. Analyses included sequential multivariable generalized linear mixed models to examine the independent relationship between PTSD and CT scan utilization. RESULTS: Among the full cohort, 13.0% (10 018 of 76 812) received at least one CT scan. PTSD was identified in 21.1% (16 182 of 76 812) of the cohort, and 22.9% (3711 of 16 182) of veterans with PTSD received at least one CT scan as compared with 10.4% (6307 of 60 630) of veterans without PTSD (P < .0001). In sequential modeling, comorbid factors explaining the relationship between CT scans and PTSD were traumatic brain injury (odds ratio, 3.54; P < .0001), abdominal pain (odds ratio, 4.01; P < .0001), and headaches (odds ratio, 3.07; P < .0001). Associations were also strong for high levels of emergency room (odds ratio, 2.73; P < .0001) and primary care (odds ratio, 2.38; P < .0001) utilization. The daily chance of receiving a CT scan was seven times higher prior to the recognition of PTSD (daily chance, 0.007 before vs 0.001 after; P < .0001). CONCLUSION: Young veterans with PTSD are receiving more CT scans compared with those without PTSD; the daily probability of receiving CT scans is higher prior to recognition of PTSD. SUPPLEMENTAL MATERIAL: http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.13121593/-/DC1.

Associations between reduced hospital length of stay and 30-day readmission rate and mortality: 14-year experience in 129 Veterans Affairs hospitals.

BACKGROUND: Reducing length of stay (LOS) has been a priority for hospitals and health care systems. However, there is concern that this reduction may result in increased hospital readmissions. OBJECTIVE: To determine trends in hospital LOS and 30-day readmission rates for all medical diagnoses combined and 5 specific common diagnoses in the Veterans Health Administration. DESIGN: Observational study from 1997 to 2010. SETTING: All 129 acute care Veterans Affairs hospitals in the United States. PATIENTS: 4,124,907 medical admissions with subsamples of 2 chronic diagnoses (heart failure and chronic obstructive pulmonary disease) and 3 acute diagnoses (acute myocardial infarction, community-acquired pneumonia, and gastrointestinal hemorrhage). MEASUREMENTS: Unadjusted LOS and 30-day readmission rates with multivariable regression analyses to adjust for patient demographic characteristics, comorbid conditions, and admitting hospitals. RESULTS: For all medical diagnoses combined, risk-adjusted mean hospital LOS decreased by 1.46 days from 5.44 to 3.98 days, or 2% annually (P < 0.001). Reductions in LOS were also observed for the 5 specific common diagnoses, with greatest reductions for acute myocardial infarction (2.85 days) and community-acquired pneumonia (2.22 days). Over the 14 years, risk-adjusted 30-day readmission rates for all medical diagnoses combined decreased from 16.5% to 13.8% (P < 0.001). Reductions in readmissions were also observed for the 5 specific common diagnoses, with greatest reductions for acute myocardial infarction (22.6% to 19.8%) and chronic obstructive pulmonary disease (17.9% to 14.6%). All-cause mortality 90 days after admission was reduced by 3% annually. Of note, hospitals with mean risk-adjusted LOS that was lower than expected had a higher readmission rate, suggesting a modest tradeoff between hospital LOS and readmission (6% increase for each day lower than expected). LIMITATIONS: This study is limited to the Veterans Health Administration system; non-Veterans Affairs admissions were not available. No measure of readmission preventability was used. CONCLUSION: Veterans Affairs hospitals demonstrated simultaneous improvements in hospital LOS and readmissions over 14 years, suggesting that as LOS improved, hospital readmission did not increase. This is important because hospital readmission is being used as a quality indicator and may result in payment incentives. Future work should explore these relationships to see whether a tipping point exists for LOS reduction and hospital readmission. PRIMARY FUNDING SOURCE: Office of Rural Health and the Health Services Research & Development Service, Veterans Health Administration, U.S. Department of Veterans Affairs.

The Academic Learning Health System: A Framework for Integrating the Multiple Missions of Academic Medical Centers.

The learning health system (LHS) has emerged over the past 15 years as a concept for improving health care delivery. Core aspects of the LHS concept include: promoting improved patient care through organizational learning, innovation, and continuous quality improvement; identifying, critically assessing, and translating knowledge and evidence into improved practices; building new knowledge and evidence around how to improve health care and health outcomes; analyzing clinical data to support learning, knowledge generation, and improved patient care; and engaging clinicians, patients, and other stakeholders in processes of learning, knowledge generation, and translation. However, the literature has paid less attention to how these LHS aspects may integrate with the multiple missions of academic medical centers (AMCs). The authors define an academic learning health system (aLHS) as an LHS built around a robust academic community and central academic mission, and they propose 6 features that emphasize how an aLHS differs from an LHS. An aLHS capitalizes on embedded academic expertise in health system sciences; engages the full spectrum of translational investigation from mechanistic basic sciences to population health; builds pipelines of experts in LHS sciences and clinicians with fluency in practicing in an LHS; applies core LHS principles to the development of curricula and clinical rotations for medical students, housestaff, and other learners; disseminates knowledge more broadly to advance the evidence for clinical practice and health systems science methods; and addresses social determinants of health, creating community partnerships to mitigate disparities and improve health equity. As AMCs evolve, the authors expect that additional differentiating features and ways to operationalize the aLHS will be identified and hope this article stimulates further discussion around the intersection of the LHS concept and AMCs.

Outcomes of a home telehealth intervention for patients with diabetes and hypertension.

BACKGROUND: Home telehealth programs often focus on a single disease, yet many patients who need monitoring have multiple conditions. This study evaluated secondary outcomes from a clinical trial evaluating the efficacy of home telehealth to improve outcomes of patients with co-morbid diabetes and hypertension. SUBJECTS AND METHODS: A single-center randomized controlled clinical trial compared two remote monitoring intensity levels (low and high) and usual care in patients with type 2 diabetes and hypertension being treated in primary care. Secondary outcomes assessed were knowledge (diabetes, hypertension, medications), self-efficacy, adherence (diabetes, medications), and patient perceptions of the intervention mode. RESULTS: Knowledge scores improved in the high-intensity intervention group participants, but upon further analysis, we found the intervention effect was not mediated by gain in knowledge. No significant differences were found across the groups in self-efficacy, adherence, or patient perceptions of the intervention mode. CONCLUSIONS: Home telehealth can enhance detection of key clinical symptoms that occur between regular physician visits. While our intervention improved glycemic and blood pressure control, the mechanism of the effect for this improvement was not clear.

Characteristics of Adult Primary Care Patients Who Use the Patient Portal: A Cross-Sectional Analysis.

BACKGROUND: The patient portal allows patients to engage with their health care team beyond the clinical encounter. While portals can improve patient outcomes, there may be disparities in which patients access the portal by sociodemographic factors. Understanding the characteristics of patients who use the portal could help design future interventions to expand portal adoption. OBJECTIVES: This study aimed to (1) examine the socioeconomic factors, comorbid conditions, and health care utilization among patients of a large academic primary care network who are users and non-users of the patient portal; and (2) describe the portal functions most frequently utilized. METHODS: We included all adult patients at Atrium Health Wake Forest Baptist who had at least two primary care visits between 2018 and 2019. Patients' demographics, comorbidities, health care utilization, and portal function usage were extracted from the electronic health record and merged with census data (income, education, and unemployment) from the American Community Survey. A myWakeHealth portal user was defined as a patient who used a bidirectional portal function at least once during the study period. We used multivariable logistic regression to determine which patient characteristics were independently associated with being a portal user. RESULTS: Of the 178,720 patients who met inclusion criteria, 32% (N = 57,122) were users of myWakeHealth. Compared to non-users, users were more likely to be 18 to 64 years of age, female, non-Hispanic White, married, commercially insured, have higher disease burden, and have lower health care utilization. Patients residing in areas with the highest educational attainment had 51% higher odds of being a portal user than the lowest (p <0.001). Among portal users, the most commonly used function was messaging clinic providers. CONCLUSION: We found that patient demographics and area socioeconomic factors were associated with patient portal adoption. These findings suggest that efforts to improve portal adoption should be targeted at vulnerable patients.

Older adults who persistently present to the emergency department with severe, non-severe, and indeterminate episode patterns.

BACKGROUND: It is well known that older adults figure prominently in the use of emergency departments (ED) across the United States. Previous research has differentiated ED visits by levels of clinical severity and found health status and other individual characteristics distinguished severe from non-severe visits. In this research, we classified older adults into population groups that persistently present with severe, non-severe, or indeterminate patterns of ED episodes. We then contrasted the three groups using a comprehensive set of covariates. METHODS: Using a unique dataset linking individual characteristics with Medicare claims for calendar years 1991-2007, we identified patterns of ED use among the large, nationally representative AHEAD sample consisting of 5,510 older adults. We then classified one group of older adults who persistently presented to the ED with clinically severe episodes and another group who persistently presented to the ED with non-severe episodes. These two groups were contrasted using logistic regression, and then contrasted against a third group with a persistent pattern of ED episodes with indeterminate levels of severity using multinomial logistic regression. Variable selection was based on Andersen's behavioral model of health services use and featured clinical status, demographic and socioeconomic characteristics, health behaviors, health service use patterns, local health care supply, and other contextual effects. RESULTS: We identified 948 individuals (17.2% of the entire sample) who presented a pattern in which their ED episodes were typically defined as severe and 1,076 individuals (19.5%) who typically presented with non-severe episodes. Individuals who persistently presented to the ED with severe episodes were more likely to be older (AOR 1.52), men (AOR 1.28), current smokers (AOR 1.60), experience diabetes (AOR (AOR 1.80), heart disease (AOR 1.70), hypertension (AOR 1.32) and have a greater amount of morbidity (AOR 1.48) than those who persistently presented to the ED with non-severe episodes. When contrasted with 1,177 individuals with a persistent pattern of indeterminate severity ED use, persons with severe patterns were older (AOR 1.36), more likely to be obese (AOR 1.36), and experience heart disease (AOR 1.49) and hypertension (AOR 1.36) while persons with non-severe patterns were less likely to smoke (AOR 0.63) and have diabetes (AOR 0.67) or lung disease (AOR 0.58). CONCLUSIONS: We distinguished three large, readily identifiable groups of older adults which figure prominently in the use of EDs across the United States. Our results suggest that one group affects the general capacity of the ED to provide care as they persistently present with severe episodes requiring urgent staff attention and greater resource allocation. Another group persistently presents with non-severe episodes and creates a considerable share of the excess demand for ED care. Future research should determine how chronic disease management programs and varied co-payment obligations might impact the use of the ED by these two large and distinct groups of older adults with consistent ED use patterns.

Effectiveness of home telehealth in comorbid diabetes and hypertension: a randomized, controlled trial.

BACKGROUND: Increased emphasis is being placed on the critical need to control hypertension (HTN) in patients with diabetes. OBJECTIVE: The objective of this study was to evaluate the efficacy of a nurse-managed home telehealth intervention to improve outcomes in veterans with comorbid diabetes and HTN. DESIGN: A single-center, randomized, controlled clinical trial design comparing two remote monitoring intensity levels and usual care in patients with type 2 diabetes and HTN being treated in primary care was used. MEASUREMENTS: Primary outcomes were hemoglobin A1c and systolic blood pressure (SBP); secondary outcome was adherence. RESULTS: Intervention subjects experienced decreased A1c during the 6-month intervention period compared with the control group, but 6 months after the intervention was withdrawn, the intervention groups were comparable with the control group. For SBP, the high-intensity subjects had a significant decrease in SBP compared with the other groups at 6 months and this pattern was maintained at 12 months. Adherence improved over time for all groups, but there were no differences among the three groups. LIMITATIONS: Subjects had relatively good baseline control for A1c and SBP; minorities and women were underrepresented. CONCLUSIONS: Home telehealth provides an innovative and pragmatic approach to enhance earlier detection of key clinical symptoms requiring intervention. Transmission of education and advice to the patient on an ongoing basis with close surveillance by nurses can improve clinical outcomes in patients with comorbid chronic illness.

Feasibility of Mobile Technology to Identify and Address Patients' Unmet Social Needs in a Primary Care Clinic.

Mobile health tools may overcome barriers to social needs screening; however, there are limited data on the feasibility of using these tools in clinical settings. The objective was to determine the feasibility of using a mobile health system to screen for patients' social needs. In one large primary care clinic, the authors tested a tablet-based system that screens patients for social needs, transmits results to the electronic health record, and alerts providers. All adult patients presenting for a nonurgent visit were eligible. The authors evaluated the feasibility of the system and conducted follow-up surveys to determine acceptability and if patients accessed resources through the process. All providers were surveyed. Of the 252 patients approached, 219 (86.9%) completed the screen. Forty-three (19.6%) required assistance with the tablet, and 150 (68.5%) screened positive for at least 1 unmet need (food, housing, or transportation). Of the 150, 103 (68.7%) completed a follow-up survey. The majority agreed that people would learn to use the tablet quickly. Forty-eight patients (46.6%) reported contacting at least 1 community organization through the process. Of the 27 providers, 23 (85.2%) completed a survey and >70% agreed the system would result in patients having better access to resources. It was feasible to use a tablet-based system to screen for social needs. Clinics considering using mobile tools will need to determine how to screen patients who may need assistance with the tool and how to connect patients to resources through the system based on the burden of unmet needs.

Pathways by Which Food Insecurity Is Associated With Atherosclerotic Cardiovascular Disease Risk.

Background Food insecurity (FI) has been associated with an increased atherosclerotic cardiovascular disease (ASCVD) risk; however, the pathways by which FI leads to worse cardiovascular health are unknown. We tested the hypothesis that FI is associated with ASCVD risk through nutritional/anthropometric (eg, worse diet quality and increased weight), psychological/mental health (eg, increased depressive symptoms and risk of substance abuse), and access to care pathways. Methods and Results We conducted a cross-sectional study of adults (aged 40-79 years) using the 2007 to 2016 National Health and Nutrition Examination Survey. Our primary exposure was household FI, and our outcome was 10-year ASCVD risk categorized as low (<5%), borderline (≥5% -<7.5%), intermediate (≥7.5%-<20%), and high risk (≥20%). We used structural equation modeling to evaluate the pathways and multiple mediation analysis to determine direct and indirect effects. Of the 12 429 participants, 2231 (18.0%) reported living in a food-insecure household; 5326 (42.9%) had a low ASCVD risk score, 1402 (11.3%) borderline, 3606 (29.0%) intermediate, and 2095 (16.9%) had a high-risk score. In structural models, we found significant path coefficients between FI and the nutrition/anthropometric (ß, 0.130; SE, 0.027; P<0.001), psychological/mental health (ß, 0.612; SE, 0.043; P<0.001), and access to care (ß, 0.110; SE, 0.036; P=0.002) pathways. We did not find a significant direct effect of FI on ASCVD risk, and the nutrition, psychological, and access to care pathways accounted for 31.6%, 43.9%, and 15.8% of the association, respectively. Conclusions We found that the association between FI and ASCVD risk category was mediated through the nutrition/anthropometric, psychological/mental health, and access to care pathways. Interventions that address all 3 pathways may be needed to mitigate the negative impact of FI on cardiovascular disease.